Overview of acute arterial occlusion of the extremities (acute limb ischemia)
- Marc E Mitchell, MD
Marc E Mitchell, MD
- Associate Professor of Surgery
- University of Mississippi School of Medicine
- Jeffrey P Carpenter, MD
Jeffrey P Carpenter, MD
- Professor and Chairman
- Department of Surgery
- Cooper Medical School of Rowan University, Camden, NJ
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
INTRODUCTION AND DEFINITIONS
According to the 2007 Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II), acute limb ischemia is defined as a sudden decrease in limb perfusion that causes a potential threat to limb viability . The threatened limb may manifest as ischemic rest pain or the development of tissue loss (ulcers, gangrene). The clinical presentation depends upon the etiology and whether the patient has underlying peripheral artery disease. Patients who present later than two weeks after the onset of the acute event are considered to have chronic limb ischemia.
The management of acute arterial occlusion remains a challenge for vascular specialists. Surgical thromboembolectomy and bypass grafting were the mainstays of therapy for many years . Subsequently, thrombolytic therapy and percutaneous transluminal angioplasty (PTA) have become treatment options for selected patients [3,4].
Despite these advances, the morbidity, mortality, and limb loss rates from acute lower extremity ischemia remain high . Thus, regardless of the treatment modality used, early diagnosis and rapid initiation of therapy are essential in order to salvage the ischemic extremity.
The major causes of, and management approaches to, acute limb ischemia will be reviewed here. Issues related to chronic limb ischemia (ie, similar manifestations in patients who present more than two weeks after symptom onset) are discussed separately. (See "Treatment of chronic lower extremity critical limb ischemia".)
Acute arterial occlusion can be the result of an embolus from a proximal source lodging into a more distal vessel, acute thrombosis of a previously patent artery, acute thrombosis of a stent or graft, and dissection of an artery or direct trauma to an artery. Common etiologies for each of these mechanisms are presented in the table (table 1).
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- INTRODUCTION AND DEFINITIONS
- Arterial emboli
- Paradoxical embolism
- Arterial thrombosis
- Arterial trauma
- EPIDEMIOLOGY AND RISK FACTORS
- Risk factors
- CLINICAL PRESENTATIONS
- Without underlying vascular disease
- With occlusive vascular disease
- PHYSICAL EXAMINATION
- Six P’s
- Blue toe syndrome
- Clinical categories of ischemia
- Vascular imaging
- DIFFERENTIAL DIAGNOSIS
- INITIAL MANAGEMENT
- Medical risk assessment
- MANAGEMENT BY SEVERITY OF ISCHEMIA
- Viable extremity
- - Thrombolytic therapy versus surgery
- - Recommendations of others
- Threatened extremity
- Nonviable extremity
- MORBIDITY AND MORTALITY
- SUMMARY AND RECOMMENDATIONS